Quarterly Form (SAP Online), Page 1

of 6 Quarterly Form (SAP Online), Page 1 1) Please enter the total number of screenings that were performed. 1-a) Please enter the number of students referred for assessment by age group, sex, and race/ethnicity in the chart below. 10 to 13 14 to 17 Male Female Male Female Male Female Male Female White (Non-Hispanic) Black (Non-Hispanic) Hispanic Asian American Indian Race 1-b) Please enter the number of students referred that received a Drug and Alcohol assessment during this reporting quarter. 1-c) Please enter the number of students referred that received a Mental Health assessment during this reporting quarter. 1-d) Please enter the number of students referred that received a Co-Occurring assessment during this reporting quarter.

of 6 Quarterly Form (SAP Online), Page 2 Assessment Results (The information should be based on the FINAL assessment) 2-a) For each age group, state the number of students whose assessment resulted in the following PRIMARY problem categories. (Include each student only ONCE in the count.): Primary Drug/Alcohol Primary Mental Health Primary Co-Occurring NONE 14-17 18 2-b) For each age group, state the number of students whose assessment resulted in the following SECONDARY problem categories. (A student may be entered more than once): Codependency Suicide Ideation Suicide Attempt Child Abuse Bullying Grief/Loss Tobacco GLBTQI Issues Trauma/ 14-17 18

of 6 Assessment Results (continued) Quarterly Form (SAP Online), Page 3 3) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY Drug and Alcohol referral category only. School Intensive non- Hosp. Rehab None

of 6 Assessment Results (continued) Quarterly Form (SAP Online), Page 4 4) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY Mental Health referral category only. School FBMHS or BHRS Residential NONE

of 6 Assessment Results (continued) Quarterly Form (SAP Online), Page 5 5) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY Cooccurring referral category only. School Intensive non- Hosp. Rehab None School FBMHS or BHRS Residential None

of 6 Referral Outcomes Quarterly Form (SAP Online), Page 6 6) Total number of students who were admitted to at least one of the or options 7) Total number of students who were not admitted to at least one of the or options Enter the number of students who were not admitted to at least one of the intervention or treatment options by category. 8a) Lack of Funds 8b) unavailable 8c) Referral refused by student 8d) Referral refused by parent 8e) Referral refused by D&A provider 8f) Referral refused by M/H provider 8g) Admission scheduled for the following quarter 8h) Client waiting list 8i) Unknown outcome 8j) 9) Enter the total number of core team consultations that the liaisons participated in the reporting quarter 10) Enter the total number of parent teacher consultations that the liaisons participated in the reporting quarter